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LETTER TO EDITOR
Year : 2020  |  Volume : 21  |  Issue : 4  |  Page : 349-350

Promising results with secukinumab in refractory pediatric psoriasis


Department of Dermatology, Command Hospital, Southern Command, Pune, Maharashtra, India

Date of Submission20-Sep-2018
Date of Decision13-Dec-2018
Date of Acceptance26-Apr-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Anwita Sinha
Department of Dermatology, Command Hospital, Southern Command, Pune-40, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_102_18

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How to cite this article:
Baveja S, Sinha A, Vashisht D, Singh PY. Promising results with secukinumab in refractory pediatric psoriasis. Indian J Paediatr Dermatol 2020;21:349-50

How to cite this URL:
Baveja S, Sinha A, Vashisht D, Singh PY. Promising results with secukinumab in refractory pediatric psoriasis. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Oct 28];21:349-50. Available from: https://www.ijpd.in/text.asp?2020/21/4/349/296839



Sir,

Pediatric psoriasis is an immune-mediated inflammatory skin disease with an incidence of 40.8/100,000 population and has recently been associated with obesity and metabolic syndrome warranting early treatment and lifestyle modification.[1] In spite of numerous treatment options, there are many children who remain refractory to these modalities. Secukinumab, an interleukin 17 (IL-17) antagonist, has yielded higher response rates than etanercept or placebo in Psoriasis Area and Severity Index (PASI) 90 and PASI 100 response at week 12.[2] However, experience of secukinumab in pediatric psoriasis is limited. Phase 3 trials are underway to assess the safety, tolerability, and long-term efficacy in individuals from 6 to <18 years of age with severe chronic plaque psoriasis with inadequate control of symptoms with topical and conventional systemic treatment.[3] Herein, we report a case of refractory pediatric psoriasis treated successfully with secukinumab.

A 13-year-old girl presented with multiple red raised flaky lesions over body of 4 years' duration with multiple exacerbations involving 50%–60% body surface area (BSA). The patient had been treated with methotrexate (MTX), phototherapy, and topical medication on multiple occasions in the past, but the disease was nonresponsive with frequent flares and unacceptable adverse effects of systemic agents in the form of gastric intolerance to MTX and noncompliance to phototherapy. She presented to our hospital with symptom exacerbation of 3 months with involvement of 60% BSA including scalp in the form of multiple polysized confluent erythematous scaly plaques [Figure 1] and [Figure 2]. Besides the cutaneous involvement, she also had significant psychological impairment in the sense that she had stopped going to school for the fear of social ostracisation. PASI was 45. Dermatology Life Quality Index (DLQI) was 23 suggesting extremely large effect on the patient's life. Investigator Global Assessment (IGA) mod 2011 was 4 (severe).
Figure 1: Multiple erythematous scaly plaques covering 60% body surface area at presentation

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Figure 2: Multiple erythematous scaly plaques covering 60% of body surface area at presentation

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In view of refractory nature of the disease severely affecting patient's quality of life, she was worked up for secukinumab. Secukinumab injections were administered with an induction period of 150 mg weekly for 4 weeks followed by 150 mg monthly for 6 months. The patient showed dramatic response with attainment of PASI 50 at 3 weeks and PASI 100 at 6 weeks of treatment [Figure 3] and [Figure 4]. Furthermore, IGA mod 2011 dropped to 0 and DLQI dropped to 7 at 6 weeks of treatment. No adverse effects were noted during the treatment and follow-up at 7 months. The patient has rejoined school, is in complete remission without any drug and is being monitored for disease relapse and any possible long-term side effect of secukinumab.
Figure 3: Psoriasis Area and Severity Index 100 attained at 6 weeks with complete resolution of the disease

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Figure 4: Psoriasis Area and Severity Index 100 attained at 6 weeks with complete resolution of the disease

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The management of pediatric psoriasis is complicated and intriguing. Children require specific guidelines for the management to support early intervention and prevention of comorbidities. However, there are currently no standardized guidelines for the treatment of pediatric psoriasis. Though not US Food and Drug Administration (FDA) approved, narrowband UV-B phototherapy, acitretin, MTX, and cyclosporine (CsA) have been used as first-line therapy for childhood psoriasis. However, adverse effects like hepatotoxicity due to cumulative dose of MTX, skeletal abnormalities with acitretin and renal toxicity, hypertension, and immunosuppression with CsA limits their use.[4]

Biologics are an attractive option for use in children because they offer more convenient dosing regimens, no cumulative toxicity in the long run and less frequent laboratory monitoring than other systemic agents. Secukinumab, approved by the US FDA for psoriasis and psoriatic arthritis in adults is a fully human monoclonal antibody that binds and neutralizes IL-17. IL-17 release increases expression of pro-inflammatory cytokines leading to recruitment of immune cells, activation of keratinocytes, and enhancement of angiogenesis leading to synovial inflammation and psoriatic plaque development. FDA approved dosing for the treatment of psoriasis with secukinumab consists of subcutaneous injections with a loading dose of once weekly 300 mg injections for the first 4 weeks for induction, followed by 300 mg every 4 weeks thereafter for maintenance for patient's more than 18 years. Our patient's age was 13 years and weight was 35 kg. Since there are no guidelines supporting the use of secukinumab in pediatric psoriasis, a dose of 150 mg s. c. was chosen based on age and weight considerations.

Secukinumab has the potential to address the unmet needs of pediatric patients with psoriasis refractory to the current treatment modalities as observed in our case with complete and rapid resolution of the disease. The most common adverse effects of secukinumab namely nasopharyngitis, upper respiratory infection, headache, neutropenia, diarrhea, and candidiasis [5] were not observed in our case.

The evidence of systemic treatment efficacy and safety in pediatric psoriasis is still limited. The therapeutic choice in children should hence be done on a case-to-case basis, with strong consideration of the effect of the disease on the patient and family and maximizing the benefit-risk ratio. Secukinumab comes forth as a promising intervention in this regard and more studies are needed to validate the same.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tollefson MM, Crowson CS, McEvoy MT, Kremers HM. Incidence of psoriasis in children: A population-based study. J Am Acad Dermatol 2010;62:979-87.  Back to cited text no. 1
    
2.
Langley RG, Elewski BE, Lebwohl M, Reich K, Griffiths CE, Papp K, et al. Secukinumab in plaque psoriasis – Results of two phase 3 trials. N Engl J Med 2014;371:326-38.  Back to cited text no. 2
    
3.
Identifier no. NCT02471144. Pediatric Study in Children and Adolescents with Severe Plaque Psoriasis. Sponsor: Novartis pharmaceuticals. Available from: http//:clinical trials.gov. [Last accessed on 2020 Mar 13].  Back to cited text no. 3
    
4.
Mendiratta V, Mittal S. Management of childhood psoriasis. Indian J Paediatr Dermatol 2012;13:12-16.  Back to cited text no. 4
  [Full text]  
5.
Roman M, Madkan VK, Chiu MW. Profile of secukinumab in the treatment of psoriasis: Current perspectives. Ther Clin Risk Manage 2015;11:1767.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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